When Obamacare passed Congress, Democrats tried to balance competing interests and minimize winners and losers. Once it's repealed, Republicans will have to do the same thing.
It's not clear that they can.
They'll try, but unless their replacement covers as many newly insured people as Obamacare, everyone who benefits from more paying customers will be hurt — and hospitals and other health care providers are bracing for the biggest hit.
The Obamacare tradeoffs:
- Insurers had to cover more expensive patients, but they were also rewarded with new, paying customers.
- Hospitals got cuts in their payments, but they also got more insured patients.
- Drug companies had to pay new fees, but in return, Democrats didn't go after them on drug prices.
The Trumpcare tradeoffs:
- When sick people gain coverage, as they do under Obamacare, healthy people pay more to cover the costs -- because that's how health insurance works.
- And if the new system is better for healthy people, it's probably going to be worse for sick people. Republicans want to cover pre-existing conditions mainly for people who have stayed insured for a long time, to keep them from only signing up when they get sick -- but not everyone can afford to stay insured.
That's why independent health care experts are skeptical of GOP promises of better health care at lower costs for more people. "I don't buy that," said Mark Pauly, a health economist at the University of Pennsylvania.
Making it work: Republicans who have worked on replacement plans think they can minimize the losers, but don't have a lot of specifics. Sen. Bill Cassidy, who wrote one of the leading plans, thinks the GOP should just try to be "fair" to everyone, possibly by giving bigger tax credits to groups with more expensive health needs.
"There's no other answer than fairness," Cassidy said. With Obamacare, he said, "there are clear winners. And there are clear losers ... So if we're fair to everybody, we're OK."
One way to minimize winners and losers: let current Obamacare customers keep their coverage and subsidies as long as they need it, and only switch to the new system when they're ready, according to James Capretta, a conservative health care expert who has worked on replacement plans.
And a lot of problems could be solved if insurers have more flexibility in the benefits they offer, according to Chris Condeluci, a consultant and member of the Axios board of experts.
If people can buy more basic, lower-cost plans than they can under Obamacare, more people might sign up and coverage might actually increase, said Condeluci, who was a Senate Republican aide during the passage of Obamacare.
Republicans do want to simplify the benefits, but it's not clear whether they'll "grandfather" the Obamacare coverage -- so the impact on the other health care sectors could be hard to control.
Why hospitals are worried: Take Chicago as an example. John Jay Shannon, chief executive officer of the Cook County Health & Hospitals System, says his hospitals needed $481 million in local taxpayer funds in fiscal year 2009. This year, it only needed $111 million.
Overall, most hospitals came out ahead under Obamacare, with big reductions in uncompensated care costs -- though hospitals in states that didn't expand Medicaid had less relief than hospitals in expansion states. Here's a chart that shows the difference.
"For the first time in the history of this safety net organization, we're taking care of a majority insured population," Shannon said. If newly insured people lose their coverage, he said, his hospitals will need more state and county funding again -- and they probably won't be able to get it.